Online Donation Form

NOTE: Please provide all information denoted with a '*'. These fields are required and are necessary to guarantee that your credit card is securely and correctly processed. This information will be used only for purposes of processing the credit card for this donation and will not be provided to another party for any reason.
     
 Donation Information
     
Donation Amount *:
$  
     
 Billing Contact Information  
     
First Name *:
 
Last Name *:
 
Company *:
 
Address *:
 
City *:
 
State:
 
Country *:
 
Zip Code *:
 
Phone *:
 
Fax:
 
E-Mail Address *:
 
     
 Credit Card Information
     
Credit Card Number *:
 
Credit Card Type *:
 
Expiration Date *:
 
     
 
If you experience technical problems using the online donation form, please contact us at info@khmerculture.net.
 

To contact us:

Friends of Khmer Culture, Inc.
P.O. Box 164, Norfolk, CT 06058-9998, U.S.A.
Phone 860 542 5677  Fax 860 542 1840